Assessment of Thoraco-abdominal injury pattern due to ... · Srinagar. 64 patients with Positive extended FAST (focused assessment with sonography for trauma) done by expert in emergency

Suhail Rafiq, Ishfaq Kuchay, Sheema, Sajad Dar. Assessment of Thoraco-abdominal injury pattern due to blunt trauma in

Kashmiri Population by contrast enhanced Computerized Tomography (CECT). IAIM, 2019; 6(6): 23-31.

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Original Research Article

Assessment of Thoraco-abdominal injury

pattern due to blunt trauma in Kashmiri

Population by contrast enhanced

Computerized Tomography (CECT)

Suhail Rafiq1*

, Ishfaq Kuchay2, Sheema

3, Sajad Dar

4

1Senior Resident, Department of Radiodiagnosis and Imaging, GMC, Srinagar, India

2Resident, Department of Radiodiagnosis and Imaging, ASCOMS, India

3Senior Resident, Department of Gynecology and Obstetrics, SKIMS, India

4Professor, Department of Radiodiagnosis and Imaging, GMC, Srinagar, India

*Corresponding author email: [email protected]

International Archives of Integrated Medicine, Vol. 6, Issue 6, June, 2019.

Copy right © 2019, IAIM, All Rights Reserved.

Available online at http://iaimjournal.com/

ISSN: 2394-0026 (P) ISSN: 2394-0034 (O)

Received on: 21-05-2019 Accepted on: 24-05-2019

Source of support: Nil Conflict of interest: None declared.

How to cite this article: Suhail Rafiq, Ishfaq Kuchay, Sheema, Sajad Dar. Assessment of Thoraco-

abdominal injury pattern due to blunt trauma in Kashmiri Population by contrast enhanced

Computerized Tomography (CECT). IAIM, 2019; 6(6): 23-31.

Abstract

Background: The most common causes of blunt abdominal trauma are motor vehicle collisions, falls

from height, assaults, and sports accidents. Computed tomographic (CT) examination of the head,

neck, chest, abdomen, and pelvis has become an essential element in the early evaluation and

decision-making algorithm for hemodynamically stable patients who sustained abdominal trauma.

Although the decision to surgically intervene is usually based on clinical criteria rather than findings

from images. CT information often increases diagnostic confidence and decreases rates of

unnecessary exploratory laparotomy.

Aim and objective: To study the pattern of Thoraco-abdominal injuries due to Blunt Trauma in

Kashmiri population.

Methods and materials: Study was done in the department of Radiodiagnosis and Imaging, GMC

Srinagar. 64 patients with Positive extended FAST (focused assessment with sonography for trauma)

done by expert in emergency Radiology were subjected to contrast enhanced CT.

Results: According to our Study, Lung was the most commonly injured organ being injured in 67%

cases followed by Spleen and Liver, being injured in 59% and 45% cases respectively. Most common

pattern of lung injury was Contusion. Grade III was the most common grade of injury followed by

Grade IV injury amongst splenic and liver injuries. Rib was the most commonly injured bone.

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Conclusion: Multidetector CT has very high accuracy for optimal evaluation of the patients with

Blunt trauma. CT plays a vital role in deciding mode of treatment whether medical or surgical for

patients with blunt trauma. Lung was the most commonly injured organ in our study followed by

Spleen and liver.

Key words

Thoracoabdominal injury, Blunt Trauma, CECT.

Introduction

The morbidity, mortality, and economic costs

resulting from trauma in general, and blunt

abdominal trauma in particular, are substantial.

The most common causes of blunt abdominal

trauma are motor vehicle collisions, falls from

height, assaults, and sports accidents [1].

Considerable forces are usually required to injure

the solid and hollow viscera in the abdomen.

Three basic mechanisms explain the damage to

the abdominal organs: deceleration, external

compression, and crushing injuries [2]. The

“panscan” (computed tomographic (CT)

examination of the head, neck, chest, abdomen,

and pelvis) has become an essential element in

the early evaluation and decision-making

algorithm for hemodynamically stable patients

who sustained abdominal trauma. In approximate

order of frequency, the most commonly injured

abdominal organs and structures are the spleen,

liver, kidneys, small bowel and/or mesentery,

bladder, colon and/or rectum, diaphragm,

pancreas, and major vessels [3], and multiple

organs are often affected simultaneously.

Various factors determine the specific

association of organs injured: the energy

delivered at impact, the part of the body struck

first, the body habitus, and, in the case of motor

vehicle accidents, the use (and type) of a restraint

device. CT is superior to clinical evaluation and

diagnostic peritoneal lavage for diagnosing

important abdominal injuries [4, 5]. Although the

decision to surgically intervene is usually based

on clinical criteria rather than findings from

images [6], CT information often increases

diagnostic confidence and decreases rates of

unnecessary exploratory laparotomy [7].

Objectives

To study the pattern of Thoraco-

abdominal injuries due to Blunt Trauma

in Kashmiri population.

Materials and methods

Study was done in the department of

Radiodiagnosis and Imaging, GMC Srinagar. 64

patients with Positive extended FAST (focused

assessment with sonography for trauma) done by

expert in emergency Radiology were subjected to

contrast enhanced CT. All of the scans were

performed using a multislice Somatom Siemens

CT scanner with a slice width of 10 mm and 3

mm reconstruction interval. Pre- and post-

contrast scans were routinely performed and

patients received 2 mL/ kg of intravenous

contrast medium (Iohexol, 300 mg/mL). The CT

scans were acquired during the portal venous

phase approximately 80 seconds after the

contrast injection. Delayed venous phase scans

were taken when there was suspicion of contrast

extravasation. Field view included both thorax

and abdomen from above the clavicles to neck to

femurs (Figure – 1 to 8).

Figure - 1: Axial CT image revealing evidence

of pulmonary contusion, pulmonary hemorrhage

and pneumothorax in same patient.



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Figure - 2: Axial CECT delayed phase image

revealing contrast extravasation in right adrenal

region with adrenal hematoma.

Figure - 3: Axial CT image with pulmonary

window revealing severe subcutaneous and

intramuscular emphysema with

pneumomediastinum.

Figure - 4: Axial CECT image revealing

evidence of Grade III splenic injury with grade I

liver injury.

Figure - 5: Axial CECT image revealing

evidence of grade III liver injury with perihepatic

free fluid.

Figure - 6: Axial CECT image revealing thick

walled jejunal loop. Patient was diagnosed with

small bowel perforation.

Figure - 7: Axial CECT image reveals evidence

of mesenteric hematoma.



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Figure - 8: Coronal CECT image reveals

evidence of grade III right renal injury.

Exclusion criteria

Patients with compromised

hemodynamic status.

Patients with history of severe contrast

reactions.

Results and Discussion

Out of 64 patients 42 were males and 22 were

females (Graph – 1). Most of the patients (21)

were in age group of 20-30 years followed by 15

in 30-40 years group (Table – 1). About 38 cases

were due to Road Traffic Accidents, 16 by fall

from heights, 8 were sports injury and 2 were

industrial accidents.

Table – 1: Catagorisation of Injured patients

based on Age Groups.

Age Group In years No. of Patients

0-10 1

10-20 11

20-30 21

30-40 15

40-50 8

50-60 6

60-70 2

Graph – 1: Gender Distribution.

Graph – 2: Site of organ injury.



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According to our Study, Lung was the most

commonly injured organ being injured in 67%

cases followed by Spleen and Liver, being

injured in 59% and 45% cases respectively. This

can be explained by the fact that lungs occupy a

large portion of chest cavity and lie in close

approximation to bony thorax. Majority of the

patients had combination of injuries (Graph –

2).

Bone fractures were seen 41 patients accounting

for 64% patients. Amongst bones rib was the

most commonly injured bone in 28 patients

followed by pubic rami and vertebra in 17 and 9

patients respectively. Multiple Rib fractures were

taken as score of 1 in our study. Most of the

patients had combinations of different bone

fractures (Graph – 3).

Graph – 3: Site of bone fracture.

Graph – 4: Pattern of lung injury.

Most common pattern of lung injury was

Contusion in 35 patients followed by

Hemothorax in 29 patients. Contusion was seen

as area of consolidation in traumatized lung).

Other patterns of Lung Injury were

pneumothorax, Pulmonary Hemorrhage (seen as

an area of Ground Glassing), laceration and

Pneumomediastinum (least common seen in 2



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patients). Most of the patients had Combination

of different patterns (Graph – 4).

Spleen and Liver Injuries were graded according

to the American Association for the Surgery of

Trauma (AAST) and accounts for the size and

location of splenic lacerations and hematomas.

Grade III was the most common grade of injury

followed by Grade IV injury. The spleen is the

most commonly injured abdominal organ in

blunt trauma. Given the role of the spleen in

immune function and the potential for

overwhelming infection after splenectomy [8],

splenic preservation after trauma is the current

standard of care. Currently, the success rate of

nonsurgical therapy varies between 80% and

90% [9] Thus, accurate identification of injuries

that may necessitate surgical or angiographic

intervention is of critical importance [10, 11, 12].

The amount of hemoperitoneum has been shown

to predict the eventual success of nonsurgical

management; patients with smaller degrees of

hemoperitoneum have higher rates of successful

nonsurgical management [13]. In addition, the

presence of active hemorrhage and/or contained

vascular injuries (pseudoaneurysms and

arteriovenous fistulae) increases the risk of failed

nonsurgical management [14]. Active

hemorrhage is identified as a contrast material

blush or focal area of hyperattenuation in or

emanating from the injured splenic parenchyma.

In our study it was present in 14 patients and is

one of the most important factor for undertaking

surgical management (Graph – 5, 6).

Graph – 5: Pattern of spleen injuries.

Graph – 6: Pattern of liver injuries.



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We had 6 cases of gut or mesenteric injuries.

Perforation was seen in 4 patients while 2

patients had mesenteric hematoma. Site of gut

perforation in our study was jejunum in all four

cases. Findings were confirmed post operatively.

Although injuries to the hollow viscera and

mesentery are rare, occurring in approximately

5% of patients with severe blunt abdominal

trauma [15, 16], one of the most essential tasks

for the emergency radiologist is to recognize the

often subtle CT signs of bowel trauma. Delays in

diagnosis as short as 8–12 hours increase the

morbidity and mortality from peritonitis and

sepsis [17]. At least one-half of injuries to hollow

viscera involve the small bowel, followed in

frequency by the colon and stomach [18].

We had 4 cases of pancreatic trauma, 2 cases of

renal trauma and adrenal injury each and one

case of Cord Transection. Pancreatic injuries

may be classified as contusion, laceration, or

transection. Contusions are focal areas of low

attenuation or enlargement. Lacerations may be

superficial or extend through the entire pancreas,

resulting in a transection (also termed fracture).

Involvement of the pancreatic duct is an

important source of morbidity and increased

mortality from complications such as infected

pseudocyst, abscess, fistulae, or sepsis [19–21].

In our study only 4 patients had pancreatic

injuries in form of contusion in 3 patients and

laceration in one patient.

AAST grading system was applied to classify the

severity of renal trauma and takes into account

the size and location of renal lacerations and

hematomas [22]. The majority of traumatic renal

injuries are treated conservatively with

observation alone [22, 23]. In our study, only 2

patients had renal injury in form of Grade III

AAST injury.

The adrenal glands are injured in approximately

2% of patients who undergo blunt abdominal

trauma (99). Major forces are required to injure

the adrenals. Not surprisingly, traumatic adrenal

hemorrhage is usually accompanied by injuries

in other upper abdominal organs, especially the

liver. Approximate distribution of adrenal

hemorrhage secondary to blunt trauma is the

right adrenal in 75% of cases, the left adrenal in

15% and both adrenals in 10% [24]. Unilateral

adrenal hematomas usually resolve

spontaneously.

About 7 patients had features of hypoperfusion

complex including combination of collapsed

infrahepatic inferior vena cava with flattening of

the renal veins, decreased caliber of the aorta,

diffusely thickened and hyper enhancing small

bowel (shock bowel), increased enhancement of

the kidneys and adrenals, decreased enhancement

of the spleen, and pancreatic enlargement with

peripancreatic and retroperitoneal edema.

Hypoperfusion factor is a poor prognostic factor.

Conclusion

Multidetector CT has very high accuracy for

optimal evaluation of the patients with Blunt

trauma. CT plays a vital role in deciding mode of

treatment whether medical or surgical for

patients with blunt trauma. Lung was the most

commonly injured organ in our study followed

by Spleen and liver.

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Assessment of Thoraco-abdominal injury pattern due to ... · Srinagar. 64 patients with Positive extended FAST (focused assessment with sonography for trauma) done by expert in emergency